Monday, June 30, 2008

Acute coronary syndrome guideline review

The American Heart Association (AHA) and the American College of Cardiology (ACC) have improved their guideline development process by writing complete guideline revisions and focused updates at more frequent intervals. The acute coronary syndrome updates (STEMI, UA/NSTEMI and PCI) are featured in this Medscape CME offering.

Changes from earlier guidelines and points of interest:

For STEMI patients an electrocardiographic definition of failed thrombolysis (an indication for rescue PCI) has replaced the angiographic definition. (IIa).

Fibrinolytic therapy should be followed by systemic anticoagulation for at least 48 hours or the duration of hospitalization, up to 8 days. Due to the risk of HIT an anticoagulant other than UFH (i.e LMWH or fondaparinux) should be used if anticoagulation persists beyond 48 hours. (I).

Clopidogrel (Plavix) is added to ASA in virtually all patients. Minimum duration of treatment (14 days to 1 year) depends on type of ACS and other management strategies. For patients receiving drug eluting stents (DES) it’s 1 year or longer. For all other NSTEMI patients (bare metal stented and unstented) the duration is 1 month or longer. For unstented STEMI patients the minimum duration is 14 days. All clopidogrel recommendations are class I.

If warfarin is indicated (e.g., atrial fibrillation) in patients on dual antiplatelet therapy the appropriate INR target is 2-2.5. (IIa).

Before implanting a DES the cardiologist should discuss the duration of antiplatelet therapy with the patient and confirm ability to comply. (Can the patient afford Plavix for a year?). (I).

If surgery is anticipated in the next year consider avoiding a DES. (I).

Polypharmacy works. The more secondary prevention drugs the patient is on, the lower the one year mortality.

Was this activity commercially biased? Discussion of the sponsor’s products, Lovenox and Plavix, did not depart from best evidence and was not preferential to evidence based alternatives. The information presented was accurate and, over all, it was a useful exercise.

I do have a minor quibble regarding transparency. I wish the presenters had made it clearer that this was not to be considered a comprehensive overview of the guidelines. The coverage of drug therapy was slanted towards antithrombotic therapy. There was some mention of beta blockers and ACE inhibitors but no mention of statins. As with any other CME presentation, the remedy for this type of problem is additional study of primary sources. The original guidelines can be accessed here.

About Me

Originally a traditional internist, I became a hospitalist in the early days of the “movement.” I'll be writing about clinical topics, mainly in hospital medicine. Occasionally politics and other stuff creep in. This content does not constitute medical advice (consult your physician) nor is it authoritative (check primary sources).